Colorado CRNAs Vs. Virginia Physicians? An interesting feud for EMS

This article came across my Twitter stream this morning. It regards a letter sent to the Centers for Medicare/Medicaid Services by the Governor of Colorado informing them that in some Colorado hospitals it is now acceptable for Certified Registered Nurse Anesthetists to work independently of physician supervision.

The article, which is in the form of a letter written to the editor of The Aspen Times, is written by a Dr. Paul Rein who is the President of the Virginia Anesthesia and Peroperative Care Specialists. He takes issue with the lack of physician oversight and is “quite concerned” about it.

I think that the letter is important for EMS people to read. Especially us EMS people that are looking at how to expand our profession, grow our scope of practice, and expand our skill sets. It shows that there are struggles over these kinds of boundary and oversight issues all over the healthcare arena and that the politics and power struggles aren’t just limited to those of us that ride ‘round in ambulances.

The full text of the letter can be found here at The Aspen Times: http://www.aspentimes.com/article/20101004/LETTER/101009942/1020&ParentProfile=1061

The parallels I can draw from this issue to EMS are striking and enlightening. Here are some of the parts of the letter that I found the most interesting:

“A nurse anesthetist is an advanced practice registered nurse who has received special training to administer anesthesia, usually being supervised by an anesthesiologist. Anesthesiologists are physicians who, after medical school, receive an additional four to five years of specialized training during residency. Not only do anesthesiologists function in the operating room but they are trained to medically evaluate patients prior to surgery and to take care of problems that may arise immediately after surgery. In a few small hospitals a nurse anesthetist may be supervised by the surgeon if there is no anesthesiologist.”

I was curious as to the educational standards of a Certified Registered Nurse Anesthetist and so I went to their National Association’s web site: Http://www.AANA.com – It says this:

“The requirements for becoming a Certified Registered Nurse Anesthetist (CRNA) mainly include having a bachelor’s degree in nursing, or other appropriate baccalaureate degree, Registered Nurse licensure, a minimum of 1 year acute care experience (ICU, ER for example), and the successful completion of both an accredited nurse anesthesia educational program and the certification examination.”

(Source: http://www.aana.com/BecomingCRNA.aspx?id=98&linkidentifier=id&itemid=98)

Huh.

Actually, I wasn’t familiar with the requirements for a CRNA before I read that, but it says that they have to have:

  • A four year degree in Something
  • Licensure as a Registered Nurse
  • A minimum of One Year Acute care experience
  • Completed an Accredited training program
  • A passing grade on the certification exam

I was curious, so I popped on over to Salary.com and typed in “Registered Nurse Anesthetist” in my own zip code for a base salary search. I found that they start out at $131,000 and top out at over $170,000 in my local area.

Then, after giving serious consideration to changing this blog from “Life Under the Lights” of Fire Trucks and Ambulances to “Life Under the Lights” of an Operating Room, I decided to point something else out about the differences and similarities of a Paramedic and a CRNA.

 “The didactic curricula of nurse anesthesia programs are governed by COA standards and provide students the scientific, clinical, and professional foundation upon which to build sound and safe clinical practice. The basic nurse anesthesia academic curriculum and prerequisite courses focus on coursework in anesthesia practice: pharmacology of anesthetic agents and adjuvant drugs including concepts in chemistry and biochemistry (105 contact hours); anatomy, physiology, and pathophysiology (135 contact hours); professional aspects of nurse anesthesia practice (45 contact hours); basic and advanced principles (sic) of anesthesia practice including physics, equipment, technology (sic)  and pain management (105 contact hours); research (30 contact hours); and clinical correlation conferences (45 contact hours).

Most programs exceed these minimum requirements. In addition, many require study in methods of scientific inquiry and statistics, as well as active participation in student-generated and faculty-sponsored research.

Clinical residencies afford supervised experiences for students during which time they are able to learn anesthesia techniques, test theory, and apply knowledge to clinical problems. Students gain experience with patients of all ages who require medical, surgical, obstetrical, dental, and pediatric interventions. The results of a 1998 survey of program directors show that nurse anesthesia programs provide an average of 1,595 hours of clinical experience for each student.”

(Again, from http://www.AANA.com – the emphasis is mine)

Remember that the CRNA’s have a Bachelor’s Degree and a RN license prior to beginning their training. This is different from the Paramedic curriculum. We have hour requirements as well:

“The emphasis of paramedic education should be competence of the graduate, not the amount of education that they receive. The time involved in educating a paramedic to an acceptable level of competence depends on many variables. Based on the experience in the pilot and field testing of this curriculum, it is expected that the average program, with average students, will achieve average results in approximately 1000-1200 hours of instruction. The length of this course will vary according to a number of factors, including, but not limited to:

-student’s basic academic skills competence

-faculty to student ratio

-student motivation

-the student’s prior emergency/health care experience

-prior academic achievements

-clinical and academic resources available

-quality of the overall educational program”

 (Source: Http://www.EMS.gov – Thanks to Chris Webster, Sam Bradley, Greg Friese and Kevin Reiter)

Not that the above is related to the article I read, I mean it’s saying that people with a BS degree in something, a medical license, and what amounts to a little more than an EMT-B class plus an EMT-P class from an accredited school make an average of $150k… but I digress.

Back to the article, Dr Rein has this to say about CRNAs:

“It is interesting to note that the United States is the only westernized country in the world that allows nurses to administer anesthesia unsupervised. Countries such as Canada, Australia, New Zealand, Japan and Israel, just to name a few, have no nurses administering anesthesia. In some European countries there are a few nurse anesthetists who work under the strict supervision of a physician.”

He continues and says this:

“So what’s up with us? Well, it seems that the American Association of Nurse Anesthetists have convinced our government in Washington that unsupervised nurses are just as safe as a physician. They point to the fact that there are no comparative studies to show they are not. The reason there are no studies is that it would be unethical to perform such a study in which some people get a physician and some do not. Can you imagine a patient agreeing to participate in such a study?”

Can you imagine indeed?

Dr Rein is right when he says in the letter that Anesthesia is a Medical profession and is a specialty of physicians for a reason. When he says “Just because we have made it safe is no reason to take it for granted”, he’s right as well. Anesthesia is dangerous for the untrained and inexperienced provider and it is a specialty not to be taken lightly. However, where’s the line? Is this an attempt by the”Virginia Anesthesia and Peroperative Care Specialists” to fire a shot at the “American Association of Nurse Anesthetists?” Are Doctor Anesthesiologists afraid of losing jobs to the nurses? Where is the line where patient safety is best maintained while being most cost-effective and efficient?

If this doesn’t provide incentive to you to think about requiring a degree for Paramedics, I don’t quite know what will. I’m not doing this job for the money and neither are you, but does that make us any more or less moral than a CRNA who “Isn’t doing his/her job for the money” either, but still makes a ton more of it than any paramedic I know?

You could change the names of the players in this argument, fiddle just a bit with some of the details, and change this into one of a thousand other feuds going on under the healthcare umbrella. This is the same story that paramedics face when we’re trying to get new skills, new techniques, more money, and more responsibility. While I’m not taking a stand on the CRNA/MD issue because it’s not my specialty, I’m offering up this debate as a study in professional growth and conflict between two of the myriad of medical camps out there. As we push EMS forward, grow as a profession, and promote the EMS 2.0 agenda, learning from things like this will be of value to us all.

————————————————–

Thanks to the following for their contributions:

  • http://twitter.com/bigdanc Dan Cummings

    I’m in agreement. Unfortunately, those degree programs that DO exist are mostly Emergency Services Administration or Fire Service degrees that happen to get you EMT-P certified. Where are the EMT-P clinical Bachelor degree and Master degree programs?

    • http://www.firegeezer.com Mike “FossilMedic” Ward

      Good question!We dropped our BSHS in Emergency Paramedicine in 2004 because:a) it could not compete with the much less expensive community college programsb) was perceived as “vocational” by medical center leadershipc) downtown lab space was almost non-existentd) significant clinical access problems e) expenses were exceeding revenue under our university business model.I am willing to explore a restart under Scope of Practice, as long as “c,” “d” and “e” are resolved. Unfortunately, “c” has gotten worse in the past six years :)MikeDirector, Emergency Health Services ProgramThe George Washington UniversityWashington, DC

    • Anonymous

      King County, Washington, Medic One has begun conferring bachelor’s degrees to its paramedic program graduates through its training provider, the University of Washington:

      http://www.washington.edu/medicine/som/depts/medex/applicants/paramedicine.htm

      • http://www.firegeezer.com Mike “FossilMedic” Ward

        Hi malamute:A unique, and academically troublesome, feature of the Univ. of Washington/Medic 1 program is the refusal to recognize potential employees/students who completed accredited training programs and are credentialed paramedics in the rest of the United States.”Other paramedic programs attended cannot be substituted.” I respect the history and the significant impact of the dedicated physician/educators at Harborview/Univ Washington. Looking at our industry, being THIS selective probably is not the model for EMS 2.0 or advanced academic accomplishments on the clinical side of the profession.But I think that it is a fantastic development for those paramedics serving in King County/Seattle.Mike

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  • http://www.firegeezer.com Mike “FossilMedic” Ward

    Chris, great post!

  • http://roguemedic.com/ Rogue Medic

    They point to the fact that there are no comparative studies to show they are not. The reason there are no studies is that it would be unethical to perform such a study in which some people get a physician and some do not. Can you imagine a patient agreeing to participate in such a study?”

    Actually, this is just another BS excuse that keeps us from finding out what works.This is the kind of nonsense that requires us to continue to treat patients with whatever has become the Standard of Care, just because some expert(s) came up with the idea long ago and everyone is too afraid to question the efficacy of this traditional, but unproven, treatment.This kind of thinking kills patients.What is unethical is for people to keep claiming that testing the unproven, but traditional way of doing things, is unethical. That is nothing but witchcraft. If all I am getting is witchcraft, why do I need a doctor?

    • Ckemtp

      I was waiting for your comment with bated breath, Sir! I wasn’t quite proud of the the way I wrote the last post that you jumped in on.. So I was hoping you’d like this one.

      Glad to have ya
      Sent from my U.S. Cellular BlackBerry® smartphone

  • JPINFV

    At the present time, I think that the CRNA vs physician (and if you want a really fun debate, look into the Doctor of Nursing Practice degree debate, which gets not only the debate about independent practice, but who should use the term “doctor” in a hospital debate. EMS thinks that the “Who get’s called an “EMT” who get’s called a “paramedic” fight is bad hasn’t seen anything yet) debate is largely inapplicable to prehospital care.

    1. CRNAs often have masters degrees, but at worst a bachelor’s degree in nursing with a post-bach program. Paramedics, in general, have an associates degree in paramedicine, and at worst have less than a year of vo-tech.

    2. CRNAs are seeking completely independent care (which, to be honest, true independence and taking full risk for their practice might be more than they bargain for). I’ve never seen, even anyplace online, US paramedics request complete independence. More liberal protocols? Sure. Completely cutting the medical director out? Nope.

    3. Nursing is a self regulated profession, paramedicine is (standard disclaimer. “Is” and “should be” are two different concepts. Just because something “is” doesn’t make it correct) a trade regulated by everyone but paramedics. Connecting 3 and 4, in general EMS providers are extremely heistant to take professional responsibility for the total care they provide and are more than happy to defer to “orders is orders, look at the protocol” when something goes wrong. This is, of course, connecting to 1. As I’ve said in other places online and will repeat here. The answer to “Why did you do _____ intervention?” should never be “protocol,” and until that time I don’t think that paramedics can be considered professionals.

    If paramedics were to become more self-regulatory (of course I could just be looking through the glasses of being a Californian. I’m a fan of the Fox series “The Academy” and I’m still trying to figure out why OCFA had an RN evaluating the medical care provided by the recruits in a scenario. Presumably there are paramedics employed by OCFA [OCFA provides 911 paramedic service to about half of Orange County] who should be smart enough to provide training feedback) and increase their education, then this might be an issue. Of course this also ignores the fact that the de facto clinical independence of paramedics due to the environment they practice in is almost unrivaled, especially for the education required. In large part, the clinical independence sought by CRNAs are already provided to paramedics since the closest a physician is to most paramedics is on the radio, not in the next room (or vehicle) over.

    -JPINFV, NREMT-B. Second year medical student.

    • http://sixlettervariable.blogspot.com Christopher

      I agree with you and would like to add that bachelor degrees in the United States approach worthlessness. It has become high school grades 13 through 16, except drinking is no longer done in your parent’s basement. BSN, whatever. AAS in Paramedicine, whatever. Both of those mean nothing under our current system of education (rote and mind numbing).

      Recently I’ve noticed masters are becoming a joke as well…

    • Tcbloom2

      Ladies & Gentlemen,
      Another piece of this issue that our colleague/competitors want to keep buried is that in the US model, anesthesia started off as a nursing specialty. The OR team was a surgeon, nurse anesthetist and the OR staff. For example, during WWII, there were 17 nurse anesthetists in this country for every one anesthesiologist. It wasn’t until 1950 when anesthesia became much more lucrative for physicians to do anesthesia that they entered the field in any numbers. CRNAs were prepared for practice w/o anesthesiologists from the start. From there you find disinformation and revisionist history. Do CRNAs practice w/o physicians? We practice with surgeons, dentists, podiatrists and all; just like anesthesiologists. You do do not see them doing anesthesia w/o another physician either. Is every CRNA right for independent practice (a misnomer – nobody practices in a truly independent practice – we are part of teams) no, some are better fitted for or choose “supervised” practice, just like some anesthesiologist (although they do not call it that). In some places, local physician groups put in place local or institutional requirements for supervision but there is governmental requirement for anesthesiologist involvement.
      In my 30+ years of practice, I have observed the greatest majority of anesthesiologists are dedicated men and women; just like CRNAs.

      • JPINFV

        First off, don’t try to redefine the term “independent practice.” You know exactly what that means, and it doesn’t mean working without a surgeon. A surgeon doesn’t over see an anesthesiologist. Additionally if CRNAs are prepared to work without anesthesiologists, why do some “choose” supervised practice? Seems like, no, not all of them are prepared.

        As far as history is concerned, how about going back to WW2 standards? As another option, since barbers used to be surgeons, next time you go for a haircut, ask if they give a discount for a haircut and appendectomy. Alternatively, we can recognize that medicine and nursing has changed over the past 70 years and that the tools and demands are more than slightly different than during WW2.

      • Cynical_Nurse

        John’s Hopkins was where Nurses trained the first Physician Anesthetists.

  • http://twitter.com/rescue_monkey Rescue Monkey

    Have you heard of the Duvall County Medical Association in Florida trying to prevent PhD RNs from using the word Doctor?

    http://jacksonville.bizjournals.com/jacksonville/stories/2010/09/13/story4.html?b=1284350400^3922871

    That’s right, MDs in the greater Jakcsonville, FL area think that DNP (Doctorate of Nursing Practice) want to call themselves “doctor” and that patients would get confused as to what provider is administering the care. Most nurses I’ve talked to say they don’t want to be called doctors, they wouldn’t degrade themselves like that.

    MDs need to look at the healthcare system and realize that there are not enough of their selective group to adequately care for the population. Nurse Practitioners and PAs are filling the gaps in Primary (family) care, CRNAs are filling the gaps in the operating rooms.

    What do you think the MDs will do when Paramedics have masters degree programs that focus on clinical care and science? I bet we’ll see the same backlash.

  • JPINFV

    You’re in the hospital and I walk in and identify myself as “Dr. JPINFV.” Are you thinking I am a physician or a nurse?

    In regards to filling the gaps, I have no problem with mid-levels filling gaps for patients willing to see them. However filling the gaps should not be done independent of physicians. It’s all good as long as long as everything is text book, but for that 1 in 10 case that isn’t text book, you’re going to want a MD or DO at least reviewing the case, not a mid-level practicing independently. Similarly, if your surgery is going to to be any sort of complicated, you’re going to want a physician anesthesiologist working on you, not a CRNA. If nurses want to practice medicine independently, they can go to medical school like everyone else who is practicing medicine.

    …and let’s not get into the inflammatory statement such as nursing not wanting to “degrade themselves.” That alone show’s that it’s more of nurses upset with their own career choice than anything else.

    • 15yrMedicCRNA

      If you really want to know about quality anesthesia care in the OR, ask the people who work there. Better yet, look at who those people choose as their anesthesia provider when they have procedures done. Ask the PACU nurses which patients do better in the recovery room. Check the stats on which patients are leaving the out patient surgery center on time. There are times when having an anesthesiologist make sense and times when it does not make sense. The argument is not solely about access to care in rural hospitals as some would have you believe, but quality of care as well. And that quality can and is being delivered every day by CRNA’s across the country. Incidentally, “any sort of complicated” can happen on any case from a bunionectomy to a craniotomy or an open heart. You don’t just look at a surgery schedule and say ooohhh, that is going to be a case that only an MDA can handle. It just does not work like that.

  • http://twitter.com/EMT_Tim EMT Tim

    Great comments and JP makes a number of good points.

    But two big things stand out to me. First, CRNA is not just EMT-B + EMT-P from an accredited school. It’s more like EMT-P with a bachelor’s degree AND then master’s level training & education to get to the six figure level.

    Second, a degree will not be getting any EMS field practitioner into the six figures the way the system works now.
    “If this doesn’t provide incentive to you to think about requiring a degree for Paramedics, I don’t quite know what will. I’m not doing this job for the money and neither are you, but does that make us any more or less moral than a CRNA who “Isn’t doing his/her job for the money” either, but still makes a ton more of it than any paramedic I know?”

    You could be an airway ninja like Kelly and maybe best any CRNA in skills, but you’re playing for the local pick-up team and the CRNA is playing in the Majors. Hospitals need skilled anesthesiology practitioners and CRNAs are cheaper (and potentially more plentiful) than anesthesiologist MDs. The difference between hospitals needing CRNAs and EMS agencies needing paramedics is money and liability. Hospitals have a lot more of both, so they can/have to demand more AND do get more from their candidates. EMS agencies tend to be happy with people who can pass the curriculum that is written on an 8th grade level.

    Thanks for sharing this post Chris, and fostering the discussion.

    • Cynical_Nurse

      Actually, it’s a four-year degree with all the extensive clinical hours of Nursing school, plus experience in your field (Critical/Intensive care only) and then a masters degree, plus a post-graduate certificate in Anesthesia with the previously mentioned clinical experience in anesthesia.

      BTW – several states already allow CRNAs to practice independently. In Washington they are the sole anesthesia provider in 72% of rural hospitals offering surgical services.

      http://www.aana.com/
      http://www.wana-crna.org/2010%20PDF/CRNAFactsWashington0710.pdf

  • http://www.emsnewbie.com/ Ron Davis

    I had a doctor friend tell me I should look at CRNA when I told him I’d got hook on medicine. He told me the reasons CRNAs got to have independent practice was that anesthesiologist got greedy. They were using CRNA’s to do more and more so they could do less and less, while still getting a cut of the CRNA’s work – like Drs do with PAs. But at some point the Nurses – which are very well organized and profession as old as Drs – realized they were being screwed and did some lobbying. They got independent practice because anesthesiologist had been arguing they were just as good in the OR when it was to their benefit.

    Don’t see this happening with PAs or paramedics for a couple of reasons.

    First neither of these groups is a well organized as the nurses and their unions.

    Second, the doctors are on guard now. They won’t let any other allied health profession get to the place CRNA’s got.

    • 15yrMedicCRNA

      Good thought Ron. I had been a paramedic for 9 years when I ran into one of my classmates in another town working as an ICU RN. He was making 2.5 x what I was in the truck. I went to nursing school. I was a charge nurse in a Level 1 trauma center and finished my BSN online and was getting ready for medical school when I had 2 4th yr residents talk me out of it. They said that if they could go to school for 3 yrs and make CRNA pay, they would have done it instead of the 8 yrs they had just invested. I went to CRNA school. Now the world is good. I work interchangeably with 3 anesthesiologists and I am not supervised. I rely on my clinical judgement just as I did when I was in the back of an ambulance or airplane, and the quality of care I provide is better because of the skills honed in the streets 17 years ago. It is unfortunate that EMS loses many of its skilled providers to other careers, but there comes a point in a persons life when your job becomes time away from your family–and not matter how much you love the work–you love your family more. When you can work less and get paid more, it means more time with your family. I still do a little volunteer firefighting to satisfy that need, but I don’t regret going back to school. Also-the argument is good about the misstep of the anesthesiologists, except-Nurses were providing anesthesia before there was such a profession as anesthesiology.

  • TheTrouthShallSetYouFree

    A few problems with your post.
    First: CRNAs do not have “a four year degree in something”. They have a BSN. A nursing specific four year degree.
    Second: The “accredited training program” to which you refers is actually a Masters of Science degree. With the requirement moving to a doctorate in the next several years.
    Third: The claim that no study have been made to compare the two professions is a complete lie. Several studies have been done, and all have concluded that care between a MDA and a CRNA is nearly identical. Anesthesia is provided by MDAs and CRNAs working independently every day, thus making it easy to compare the two without assigning one group of people to MDAa, and one group to CRNAs.
    Fourth: The claim that MDs and DOs made anesthesia safe is ridiculous. Nurses were the first providers of anesthesia, not doctors. They only got into the game when they saw the potential to make big money, and through the lobbying support of the AMA.
    In several states CRNAs are allowed to work independently already. In most of the other states all that is required is the supervision of ANY doctor, no MDA required. Of the few states that do require MDA supervision, you can be assured that the MDA is “supervising” maximum number allowed by law, while the CRNAs do all of the real patient care.
    If the use of CRNAs was unsafe they would not provide over 32 million anesthetics in the us each year, and nearly 100% of all anesthetics in rural hospitals.
    The only reason that this has become an issue is the fact that a CRNA working independently does not have to give a cut of their pay to an MDA. MDAs had no problems as long as they got their checks.

    • Truthteller

      …those studies were based on ASA classified I and II patients (healthy patients) and the funding was provided by the AANA (nursing anesthetists) …. which leads to a biased result.

      ….as for the first to provide anesthesia, it was a dentist named Horace Wells. Topical anesthesia…a physician named Carl Koller.

      Funny how facts get misquoted.

      My favorite: “Physicians went where the money was.”

  • Crsnbarb

    CRNAs do practice independently in many Western countries. The statement that they do not
    is false. This information comes to me from an anesthesiologist in Belgium, where CRNAs practice independently.

    • NHCRNA

      CRNAs practice in many countries around the world, not just the USA and Europe. If you google IFNA you can find more information about all the other countries where nurse anesthetists work.
      Anesthesia is the practice of nursing when provided by CRNAs, and it is the practice of medicine when provided by a physician.
      CRNAs were the first to provide anesthesia, then physicians followed the money many years later. CRNAs also provide the majority of US military anesthesia care, with some military physician anesthetists.
      While as a previous poster said, many physician anesthetists are excellent and great people, there is a militant core in their midst that won’t come to grips with CRNAs providing anesthesia, unless it is a highly supervised and subservient environment. Nothing rankles more than having another person stand there and tell one exactly what to do when you are already trained to do it, and experienced as well.

      • Tj Edwards

        This reply draws direct parallels with the intubation debate in the UK.

        Anesthetists are claiming that studies show paramedics can’t intubate. unfortunately the studies are from other countries and mostly in hospital. They haven’t got any meaningful data to prove their assertions. Debate based on flawed data decreases the credibility of their argument. Some paramedics (eg UK CCPs) are more than proficient at intubating as they do it daily.

        As we increase our academic credentials we increase our ability to debate these issues and provide increasing levels of pt care, like leaving people at home.

        Tj.

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Chris Kaiser aka "Ckemtp"

I am a paramedic trying to advance the idea that the Emergency Medical Services can be made into the profession that we all want it, need it, and know it deserves to be.

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  • Comments
    mr618
    Welcome to the Club
    Well said, Chris. We can't save everybody, but the ones we don't save tend to stick around a lot longer than the ones we do save.
    2014-10-18 14:40:00
    Steel City Medic
    Welcome to the Club
    Particularly appropriate for me this week. Thanks.
    2014-09-23 21:46:00
    DiverMedic
    Welcome to the Club
    Very well done, Chris.
    2014-09-17 22:15:00
    DiverMedic
    My Blogroll
    One of these days you'll figure out where my blog is... :)
    2014-09-17 22:11:00
    emtterri123
    Six Tricks You Can Use Today to Improve Your EMS Narrative Report
    The first and best way to get people reading you to think that you are an idiot is to pepper your writing with spelling and grammatical errors. It makes you look dumb. - Me thinks this should have been restructured as it does not flow and caused me to reread it several times. lol :)
    2014-09-17 08:27:00

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